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Background: Despite advances in surgery and pharmacotherapy, there remains significant residual ischemic risk after coronary artery bypass grafting surgery. Methods: In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial), a multicenter, placebo-controlled, double-blind trial, statin-treated patients with controlled low-density lipoprotein cholesterol and mild to moderate hypertriglyceridemia were randomized to 4 g daily of icosapent ethyl or placebo. They experienced a 25% reduction in risk of a primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, coronary revascularization, or hospitalization for unstable angina) and a 26% reduction in risk of a key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) when compared with placebo. The current analysis reports on the subgroup of patients from the trial with a history of coronary artery bypass grafting. Results: Of the 8179 patients randomized in REDUCE-IT, a total of 1837 (22.5%) had a history of coronary artery bypass grafting, with 897 patients randomized to icosapent ethyl and 940 to placebo. Baseline characteristics were similar between treatment groups. Randomization to icosapent ethyl was associated with a significant reduction in the primary end point (hazard ratio [HR], 0.76 [95% CI, 0.63–0.92]; P =0.004), in the key secondary end point (HR, 0.69 [95% CI, 0.56–0.87]; P =0.001), and in total (first plus subsequent or recurrent) ischemic events (rate ratio, 0.64 [95% CI, 0.50–0.81]; P =0.0002) compared with placebo. This yielded an absolute risk reduction of 6.2% (95% CI, 2.3%–10.2%) in first events, with a number needed to treat of 16 (95% CI, 10–44) during a median follow-up time of 4.8 years. Safety findings were similar to the overall study: beyond an increased rate of atrial fibrillation/flutter requiring hospitalization for at least 24 hours (5.0% vs 3.1%; P =0.03) and a nonsignificant increase in bleeding, occurrences of adverse events were comparable between groups. Conclusions: In REDUCE-IT patients with a history of coronary artery bypass grafting, treatment with icosapent ethyl was associated with significant reductions in first and recurrent ischemic events. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01492361.

Aquaculture, especially fish farming, plays a vital role in ensuring food security in the United States and worldwide. However, for fish farming to be sustainable and economically viable, drastic improvements to the current labor-intensive and resource-inefficient operations are required. The hybrid aerial/underwater robotic system (HAUCS) aims to bring fundamental innovations to how pond-based farms operate. HAUCS is an end-to-end framework that consists of three principal subsystems: 1) a team of collaborative aero-amphibious robotic sensing platforms integrated with water quality sensors; 2) a land-based home station that can provide automated charging and sensor cleaning; and 3) a backend processing center that includes a machine-learning-based water quality prediction model and farm control center. HAUCS will be capable of collaborative monitoring and decision-making on farms of varying scales. The HAUCS platform, payload, and prediction model are discussed. The initial deployment of the HAUCS framework at a land-based aquaculture fish farm is presented.

Background Patient-reported outcome measures (PROMs) are validated questionnaires that are completed by patients. Arthroplasty registries vary in PROM collection and use. Current information about registry collection and use of PROM is important to help improve methods of PROMs data analysis, reporting, comparison, and use toward improving clinical practice. Questions/purposes To characterize PROM collection and use by registries, we asked: (1) What is the current practice of PROM collection by arthroplasty registries that are current or former members of the International Society of Arthroplasty Registries, and are there sufficient similarities in PROM collection between registries to enable useful international comparisons that could inform the improvement of arthroplasty care? (2) How do registries differ in PROM administration and demographic, clinical, and comorbidity index variables collected for case-mix adjustment in data analysis and reporting? (3) What quality assurance methods are used for PROMs, and how are PROM results reported and used by registries? (4) What recommendations to arthroplasty registries may improve PROM reporting and facilitate international comparisons? Methods An electronic survey was developed with questions about registry structure and collection, analysis, reporting, and use of PROM data and distributed to directors or senior administrators of 39 arthroplasty registries that were current or former members of the International Society of Arthroplasty Registries. In all, 64% (25 of 39) of registries responded and completed the survey. Missing responses from incomplete surveys were captured by contacting the registries, and up to three reminder emails were sent to nonresponding registries. Recommendations about PROMs collection were drafted, revised, and approved by the International Society of Arthroplasty Registries PROMs Working Group members. Results Of the 25 registries that completed the survey, 15 collected generic PROMs, most frequently the EuroQol-5 Dimension survey; 16 collected joint-specific PROMs, most frequently the Knee Injury and Osteoarthritis Outcome Score and Hip Disability and Osteoarthritis Outcome Score; and 11 registries collected a satisfaction item. Most registries administered PROM questionnaires within 3 months before and 1 year after surgery. All 16 registries that collected PROM data collected patient age, sex or gender, BMI, indication for the primary arthroplasty, reason for revision arthroplasty, and a comorbidity index, most often the American Society of Anesthesiologists classification. All 16 registries performed regular auditing and reporting of data quality, and most registries reported PROM results to hospitals and linked PROM data to other data sets such as hospital, medication, billing, and emergency care databases. Recommendations for transparent reporting of PROMs were grouped into four categories: demographic and clinical, survey administration, data analysis, and results. Conclusion Although registries differed in PROM collection and use, there were sufficient similarities that may enable useful data comparisons. The International Society of Arthroplasty Registries PROMs Working Group recommendations identify issues that may be important to most registries such as the need to make decisions about survey times and collection methods, as well as how to select generic and joint-specific surveys, handle missing data and attrition, report data, and ensure representativeness of the sample. Clinical Relevance By collecting PROMs, registries can provide patient-centered data to surgeons, hospitals, and national entities to improve arthroplasty care.

Older persons with serious illnesses living in rural communities are an underserved population. They often live with heavy symptom burden and poor quality of life with limited access to resources. Nav-CARE (Navigation: Connecting Accessing Resourcing and Engaging) was developed to specially train and mentor volunteer navigators who help connect older persons with serious illness to the resources and information they need. Aims: This mixed methods longitudinal study evaluated Nav-CARE for feasibility, acceptability, ease of use, and satisfaction by older persons and volunteers. Methods: Nine volunteer navigators visited 23 older persons with serious illness every 3 to 4 weeks for 1 year. Data were collected from volunteer navigators, and older person participants at baseline, during the year- long implementation and post implementation. Results: Volunteer navigators and older persons reported Nav-CARE was easy to use, feasible and acceptable. The majority of older persons agreed or strongly agreed that they were satisfied with the navigation services (100%; 8/8), that navigation services were important to them (87%; 7/8), that they would recommend the program to someone else (87%; 7/8), and would participate in the program again (75%; 6/8). Similarly, volunteer navigators reported 100% (9/9) satisfaction with the program, 100% (9/9) would recommend it to others, and 67% (6/8) would participate again. Conclusions: Nav-CARE appears to be a feasible, acceptable, and satisfactory program for older persons with serious illness and volunteer navigators.

OBJECTIVE To assess the efficacy of erenumab at the ≥50%, ≥75%, and 100% reduction in monthly migraine days (MMD) response thresholds, using data from the 6-month double-blind treatment phase (DBTP) of the Study to Evaluate the Efficacy and Safety of Erenumab in Migraine Prevention (STRIVE) pivotal clinical trial. METHODS Enrolled patients with episodic migraine (EM; ≥4 MMD and

BACKGROUND AND PURPOSE: Cavernous malformations occur most often in the brain but can occur in the spinal cord. Small studies of patients with familial cerebral cavernous malformations suggested a prevalence of spinal cord cavernous malformations of 20%–42%. We aimed to review our familial cohort and prospectively estimate the prevalence of spinal cord cavernous malformations. MATERIALS AND METHODS: We initially reviewed our familial cerebral cavernous malformations cohort for spinal cord cavernous malformations and reviewed clinical spine MR imaging examinations for sequence sensitivity. We then prospectively performed research MR imaging of the spinal cord in 29 patients from the familial cohort to estimate the prevalence. RESULTS: Gradient-based sequences identified the most spinal cord cavernous malformations on clinical MR images, forming the basis for developing our screening MR imaging. Screening spinal cord MR imaging demonstrated a prevalence of 72.4%, and a positive correlation with patient age and number of cerebral cavernous malformations. CONCLUSIONS: Spinal cord cavernous malformations occur commonly in the familial cerebral cavernous malformation population. Gradient-based sequences are the most sensitive and should be used when spinal cord cavernous malformations are suspected. This study establishes the prevalence in the familial population at around 70% and supports the idea that this condition is a progressive systemic disease that affects the entire central nervous system.

BACKGROUND: Patient-reported outcome measures (PROMs) are validated questionnaires that are completed by patients. Arthroplasty registries vary in PROM collection and use. Current information about registry collection and use of PROMs is important to help improve methods of PROM data analysis, reporting, comparison, and use toward improving clinical practice. QUESTIONS/PURPOSES: To characterize PROM collection and use by registries, we asked: (1) What is the current practice of PROM collection by arthroplasty registries that are current or former members of the International Society of Arthroplasty Registries, and are there sufficient similarities in PROM collection between registries to enable useful international comparisons that could inform the improvement of arthroplasty care? (2) How do registries differ in PROM administration and demographic, clinical, and comorbidity index variables collected for case-mix adjustment in data analysis and reporting? (3) What quality assurance methods are used for PROMs, and how are PROM results reported and used by registries? (4) What recommendations to arthroplasty registries may improve PROM reporting and facilitate international comparisons? METHODS: An electronic survey was developed with questions about registry structure and collection, analysis, reporting, and use of PROM data and distributed to directors or senior administrators of 39 arthroplasty registries that were current or former members of the International Society of Arthroplasty Registries. In all, 64% (25 of 39) of registries responded and completed the survey. Missing responses from incomplete surveys were captured by contacting the registries, and up to three reminder emails were sent to nonresponding registries. Recommendations about PROM collection were drafted, revised, and approved by the International Society of Arthroplasty Registries PROMs Working Group members. RESULTS: Of the 25 registries that completed the survey, 15 collected generic PROMs, most frequently the EuroQol-5 Dimension survey; 16 collected joint-specific PROMs, most frequently the Knee Injury and Osteoarthritis Outcome Score and Hip Disability and Osteoarthritis Outcome Score; and 11 registries collected a satisfaction item. Most registries administered PROM questionnaires within 3 months before and 1 year after surgery. All 16 registries that collected PROM data collected patient age, sex or gender, BMI, indication for the primary arthroplasty, reason for revision arthroplasty, and a comorbidity index, most often the American Society of Anesthesiologists classification. All 16 registries performed regular auditing and reporting of data quality, and most registries reported PROM results to hospitals and linked PROM data to other data sets such as hospital, medication, billing, and emergency care databases. Recommendations for transparent reporting of PROMs were grouped into four categories: demographic and clinical, survey administration, data analysis, and results. CONCLUSION: Although registries differed in PROM collection and use, there were sufficient similarities that may enable useful data comparisons. The International Society of Arthroplasty Registries PROMs Working Group recommendations identify issues that may be important to most registries such as the need to make decisions about survey times and collection methods, as well as how to select generic and joint-specific surveys, handle missing data and attrition, report data, and ensure representativeness of the sample. CLINICAL RELEVANCE: By collecting PROMs, registries can provide patient-centered data to surgeons, hospitals, and national entities to improve arthroplasty care.

Analysis of wireless traffic in urban environments accelerate solutions to challenging problems, such as pedestrian localization for safety monitoring and traffic optimization and device identification for marketing outreach. Many wireless testbeds provide rich experimentation capabilities. However, most are complex, expensive, and slow to deploy due to the advanced knowledge needed to configure the infrastructure. We present a solution that addresses these challenges. The testbed described in this paper provides infrastructure that is easy to adopt, inexpensive, and includes streamlined support for conducting largescale urban wireless traffic collection. We leverage infrastructure designed for the ongoing Mobility Intelligence Project in the City of West Palm Beach, Florida. Since its original deployment, we have discovered and addressed numerous system stability, data processing, and storage challenges. In this paper, we describe these enhancements and several testbed use-case scenarios.

Rural communities in Canada have faced a long history of capital and labour flight, resource extraction, and political marginalization. At the same time, despite decades of efforts toward rural development and economic/social diversification, there is little evidence of change or improved resilience in rural Canada. This article seeks to examine this lack of change against the backdrop of that developmental history, and the underlying logics that have informed rural policy-making. Focusing on Alberta, this paper argues that rural communities face a third phase of developmental approaches embedded within a neoliberal governmentality, one that emphasizes equality of opportunity, competition, capacity-building, and collaboration. This approach is simultaneously situated within a broader neoliberal objective of defining both citizens and rural communities as economic actors. In turn, this article examines the scope, scale, and role of energy and agricultural investments as a demonstration of how neoliberal governmentality structures not only how rural development is framed, but constructs economic agency for rural communities as “the only game in town” for the very populations that bear the costs. As a result, the historical failure of rural development is unlikely to change, yet, rather than be understood as problematic, will increasingly be seen as a failure on the part of rural communities themselves., Les collectivités rurales du Canada connaissent depuis longtemps la fuite des capitaux et de la main-d’oeuvre, l’extraction des ressources et la marginalisation politique. En même temps, malgré des décennies d’efforts de développement rural et de diversification économique et sociale, il y a peu de signes de changement ou d’amélioration de la résilience dans le Canada rural. Le présent article cherche à examiner cette absence de changement à la lumière de cette histoire du développement et des logiques sous-jacentes qui ont guidé l’élaboration des politiques rurales. En se concentrant sur l’Alberta, cet article soutient que les collectivités rurales font face à une troisième phase d’approches de développement ancrées dans une gouvernance néolibérale, qui met l’accent sur l’égalité des chances, la concurrence, le renforcement des capacités et la collaboration. En même temps, cette approche s’inscrit dans un objectif néolibéral plus large qui consiste à définir les citoyens et les communautés rurales comme des acteurs économiques. Cet article examine à son tour la portée, l’ampleur et le rôle des investissements dans les secteurs de l’énergie et de l’agriculture afin de montrer comment la gouvernance néolibérale structure non seulement le développement rural, mais fait de l’autonomie économique des communautés rurales « la seule option possible », y compris pour les populations qui en subissent le coût. Par conséquent, il est peu probable que l’échec historique du développement rural change, mais plutôt que d’être considéré comme problématique, il sera de plus en plus perçu comme un échec par les communautés rurales elles-mêmes.

Objective Most studies on preoperative opioid use only describe whether or not patients use opioids without characterizing reasons for use. Knowing why patients use opioids can help inform perioperative opioid management. The objective of this study was to explore pain specific reasons for preoperative opioid use prior to total hip and knee arthroplasty (THA and TKA) and their association with persistent use. Methods This is a prospective study of 197 patients undergoing THA (n = 99) or TKA (n = 98) enrolled in the Analgesic Outcomes Study between December 2015 and November 2018. All participants reported preoperative opioid use. Results Reasons for preoperative opioid use were categorized as surgical site pain only (81 [41.1%]); pain in other body areas only (22 [11.2%]); and combined pain (94 [47.7%]). Compared to patients taking opioids for surgical site pain, those with combined reasons for use had 1.24 (P = .40) and 2.28 (P = .16) greater odds of persistent use at 3 and 6 months postoperatively, adjusting for relevant covariates. Conclusions This study provides novel insights into the heterogeneity of reasons for presurgical opioid use in patients undergoing a THA or TKA. One key take away is that not all preoperative opioid use is the same and many patients are taking opioids preoperatively for more than just pain at the surgical site. Combined reasons for use was associated with long-term use, suggesting nonsurgical pain, in part, drives persistent opioid use after surgery. Future directions in perioperative care should focus on pain and non-pain reasons for presurgical opioid use to create tailored postoperative opioid weaning plans.

Heather A Chubb,1 Eric R Cornish,2 Brian R Hallstrom,1 Richard E Hughes1 1Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA; 2Department of Orthopedic Surgery, MidMichigan Health, Alpena, MI, USACorrespondence: Richard E HughesDepartment of Orthopaedic Surgery, University of Michigan, 2003 BSRB, 109 Zina Pitcher Pl, Ann Arbor, MI, 48109-2200, USAFax +1 734 647-0004Email rehughes@umich.eduBackground: Benchmarking arthroplasty implant revision risk is an informative way to address implant performance. National benchmarking efforts exist in the United Kingdom, Netherlands, and Australia. Recently, the International Prosthesis Benchmarking Working Group, including representatives from industry, academia, and national registries, produced a guideline describing arthroplasty benchmarking methodology. The proposal was applied to data from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) to assess its feasibility for benchmarking implants in the United States.Methods: Primary elective total hip arthroplasty procedures performed for osteoarthritis between 2/15/2012 and 12/31/2018 and their associated revisions were identified in the MARCQI registry. The guidelines recommend that all prostheses combinations receive an early benchmark if they have at least 250 procedures at risk and the revision rate does not exceed the pre-determined standard of 2% at 2 years and 3% at 5 years.Results: A total of 72,949 primary cases met the inclusion criteria. Of these, 1369 had revisions. Twenty-nine and six stem/cup combinations satisfied the minimum case requirement at 2 and 5 years, respectively. Three implant combinations would not receive a benchmark at 2 years: Secur-Fit/Trident, Anthology/Reflection 3, Taperloc 133/G7.Conclusion: The guideline can be implemented in the United States by a regional registry. Moreover, not all hip implants currently in use would receive an early benchmark. This raises concern as these implant combinations represent a significant number of cases in Michigan, some with increasing utilization.Keywords: arthroplasty, hip, implant, benchmarking, revision

Venous thromboembolism is a well-established complication of total hip and knee arthroplasty and hip fracture surgery. Clinical practice guidelines have been proposed to help clinicians provide prophylaxis against this risk. However, most guidelines reference data that are becoming outdated because of new advances in perioperative protocols. Recent data would suggest that aspirin may be appropriate for most patients after total hip and knee replacement and a more potent chemoprophylaxis for higher risk patients. Low-molecular-weight heparin remains the recommended choice after hip fracture surgery, although there is a paucity of recent literature in this patient population. There are randomized trials currently underway in the arthroplasty population that may guide clinicians in the appropriate choice of chemoprophylaxis. These studies should inform updates to the current clinical practice guidelines.

Uncertainty remains surrounding the use of aspirin as a sole chemoprophylactic agent to reduce the risk of venous thromboembolism (deep vein thrombosis or pulmonary embolism) and bleeding after primary total hip arthroplasty.We performed a non-inferiority analysis of a retrospective cohort of patients undergoing total hip arthroplasty from April 1, 2013 to December 31, 2018. Cases were retrieved from the Michigan Arthroplasty Registry Collaborative Quality Initiative database and performed by 355 surgeons at 61 hospitals throughout Michigan. Surgical setting ranged from small community hospitals to large academic and non-academic centers. The primary outcomes were post-operative venous thromboembolism event or death and bleeding event.Of the 59,747 patients included, 32,878 (55.03%) were female, and the mean age was 64.5. A total of 462 (0.77%) composite venous thromboembolism events occurred. There were 221 (0.71%) and 129 (0.80%) venous thromboembolism events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for composite venous thromboembolism events (odds ratio 0.99, 95% confidence interval 0.79-1.26, P.001). Bleeding events occurred in 767 (1.28%) patients, with 304 (0.97%) and 281 (1.74%) bleeding events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for bleeding events (odds ratio 0.62, 95% confidence interval 0.52-0.74, P.001).Aspirin is not inferior to other anticoagulants as pharmacologic venous thromboembolism prophylaxis with regards to post-operative risk of venous thromboembolism or bleeding. Sole use of aspirin for venous thromboembolism prophylaxis after total hip arthroplasty should be considered in the appropriate patient.

Object-based development using design-by-contract (DbC) is broadly taught and practiced. Students must be able to read and write symbolic DbC assertions that are sufficiently precise and be able to use these assertions to trace program code. This paper summarizes the results of using an automated tool to pinpoint fine-grain difficulties students face in learning to symbolically trace code involving objects. The pilots were conducted in an undergraduate software engineering course. Quantitative results show that data collected by the tool can help to identify and classify learning obstacles. Qualitative findings help validate student misunderstandings underlying these difficulties. Analysis of exam questions helps understand the persistence of student learning to read and write simple assertions about code behavior. Together, these results provide directions for intervention.

IMPORTANCE: Consensus guidelines and systematic reviews have suggested that cemented fixation is more effective than uncemented fixation in hemiarthroplasty for displaced femoral neck fractures. Given that these recommendations are based on research performed outside the United States, it is uncertain whether these findings also reflect the US experience. OBJECTIVE: To compare the outcomes associated with cemented vs uncemented hemiarthroplasty in a large US integrated health care system. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 12 491 patients aged 60 years and older who underwent hemiarthroplasty treatment of a hip fracture between 2009 and 2017 at 1 of the 36 hospitals owned by Kaiser Permanente, a large US health maintenance organization. Patients were followed up until membership termination, death, or the study end date of December 31, 2017. EXPOSURES: Hemiarthroplasty (prosthetic replacement of the femoral head) fixation via bony growth into a porous-coated implant (uncemented) or with cement. MAIN OUTCOMES AND MEASURES: The primary outcome measure was aseptic revision, defined as any reoperation performed after the index procedure involving exchange of the existing implant for reasons other than infection. Secondary outcomes were mortality (in-hospital, postdischarge, and overall), 90-day medical complications, 90-day emergency department visits, and 90-day unplanned readmissions. RESULTS: Among 12 491 patients in the study cohort who underwent hemiarthroplasty for hip fracture (median age, 83 years; 8660 women [69.3%]), 6042 (48.4%) had undergone uncemented fixation and 6449 (51.6%) had undergone cemented fixation, and the median length of follow-up was 3.8 years. In the multivariable regression analysis controlling for confounders, uncemented fixation was associated with a significantly higher risk of aseptic revision (cumulative incidence at 1 year after operation, 3.0% vs 1.3%; absolute difference, 1.7% [95% CI, 1.1%-2.2%]; hazard ratio [HR], 1.77 [95% CI, 1.43-2.19]; P

This is an open-access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modification or adaptations are made.

Mobility monitoring in urban environments provides valuable insights into pedestrian and vehicle movement. Understanding the causes and effects of changing mobility patterns can help city officials and businesses optimize operations and support economic development. In this paper, we introduce MobIntel, a privacy-centric alternative to visual surveillance for mobility monitoring. We present the design, implementation, and evaluation of the MobIntel sensor network, the associated cloud-based processing system, and the web-based visualization portal. We evaluate system capacity and accuracy based on real-life data collected from a deployment in downtown West Palm Beach, FL, spanning 14 months. We offer sample use cases where pedestrian activity patterns revealed by MobIntel can be helpful to the city government. Finally, we discuss several obstacles that must be overcome to transition from pedestrian counting to trajectory monitoring.

• Rural communities in Canada have diverse forms and processes of sustainability planning.

Recent standards, legislation, and best practices point to data center infrastructure management systems to control and monitor data center performance. This work presents an innovative approach to address some of the challenges that currently hinder data center management. It explains how monitoring and management systems should be envisioned and implemented. Key parameters associated with data center infrastructure and information technology equipment can be monitored in real-time across an entire facility using low-cost, low-power wireless sensors. Given the data centers’ mission critical nature, the system must be reliable and deployable through a non-invasive process. The need for the monitoring system is also presented through a feedback control systems perspective, which allows higher levels of automation. The data center monitoring and management system enables data gathering, analysis, and decision-making to improve performance, and to enhance asset utilization.

Background The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) has monitored discharge disposition, after total hip and knee arthroplasties, since inception in 2012 and found the standardized risk of extended care facility (ECF) placement to be highly variable between hospitals. Methods The variation in standardized risks of ECF placement among MARCQI member sites was reported to the collaborative. At the May 2, 2014 quarterly meeting, a quality initiative was started, emphasizing the wide variability between hospitals, the contribution of hospital and surgeon to that variability using median odds ratios, and the need for outlier hospitals to initiate quality improvement (QI) processes. Patients from 29 hospitals that were members of MARCQI before the intervention were included in this analysis. We compared standardized risks before and after the intervention in the entire cohort, and for 3 hospitals that implemented institution-specific QI projects. We report changes in ECF placement, length of stay, emergency room visits, and readmissions over time. Results This study includes 31,347 patients before and 20,879 patients after the implementation of the quality initiative. The range in standardized risk dropped from 9.4%-46.1% to 9.4%-32.4% and the average dropped from 23.0% to 19.6%. Three outlier hospitals decreased their absolute risk of ECF placement by 12.2%, 8.9%, and 12.4% after QI, without increases in adverse outcomes. Conclusion Discharge to ECF after primary hip and knee arthroplasties is highly variable and influenced by hospital and surgeon practices. Hospital-level QI measures can decrease ECF admissions.

// Chencheng Xie 1 , Matthew J. Freeman 1 , Huarui Lu 1 , Xiaohong Wang 1 , Colleen L. Forster 2 , Aaron L. Sarver 3 and Timothy C. Hallstrom 1 1 Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA 2 BioNet, Academic Health Center, University of Minnesota, Minneapolis, MN, USA 3 Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA Correspondence to: Timothy C. Hallstrom, email: // Keywords : retinoblastoma, AKT, NVP-BEZ235, carboplatin, topotecan Received : October 19, 2016 Accepted : March 10, 2017 Published : April 08, 2017 Abstract Retinoblastoma is a pediatric cancer of the retina most often caused by inactivation of the retinoblastoma ( RB1) tumor suppressor gene. We previously showed that Rb1 loss cooperates with either co-activating the phosphatidylinositol 3-kinase (PI3K)/AKT pathway, or co-deleting Pten, to initiate retinoblastoma tumors in mice. The objectives of this study were to determine if the AKT pathway is activated in human retinoblastomas and the extent that anti-PI3K therapy induces apoptosis in retinoblastoma cells, alone or in combination with the DNA damaging drugs carboplatin and topotecan. Serial sections from human retinoblastoma tissue microarrays containing 27 tumors were stained with antibodies specific to p-AKT, Ki-67, forkhead box O1 (p-FOXO1), and ribosomal protein S6 (p-S6) using immunohistochemistry and each tumor sample scored for intensity. Human retinoblastoma tumors displayed significant correlation between p-AKT intensity with highly proliferative tumors ( p = 0.008) that were also highly positive for p-FOXO1 ( p = 0.002). Treatment with BEZ235, a dual PI3K/mTOR inhibitor, reduced phosphorylation levels of the AKT targets p-FOXO and p-S6 and effectively induced apoptosis the Y79 and Weri-1 human retinoblastoma cell lines and in vivo in our retinoblastoma mouse model. Long-term treatment with BEZ235 in vivo using our retinoblastoma-bearing mice induced apoptosis but did not significantly extend the lifespan of the mice. We then co-administered BEZ235 with topotecan and carboplatin chemotherapeutics in vivo , which more effectively induced apoptosis of retinoblastoma, but not normal retinal cells than either treatment alone. Our study has increased the variety of potentially effective targeted treatments that can be considered for human retinoblastoma.

National and regional arthroplasty registries have proliferated since the Swedish Knee Arthroplasty Register was started in 1975. Registry reports typically present implant-specific estimates of revision risk and patient- and technique-related factors that can inform clinical decision-making about implants and techniques. However, annual registry reports are long and it is difficult for clinicians to extract comparable revision risk data. Since implants may appear in multiple registry reports, it is even more difficult to gather relevant data for clinical decision-making about implant selection. The purpose of this paper is to briefly describe arthroplasty registry concepts, international registries around the world, US registries, and provide a parsimonious summary of total hip arthroplasty (THA) implant revision risk reports across registries.Revision risk data for conventional stem/cup combinations reported by the Australian, R.I.P.O. (Italian), Finnish, and Danish registries are summarized here. These registries were selected because they presented 10-year data on revision risk by stem/cup combination. Four tables of revision risk are presented based on fixation: cemented, uncemented, hybrid, and reverse hybrid. Review of these tables show there is wide variation in revision risk across conventional THA implants. It also demonstrates that some cemented implants have better 10-year risk than the best uncemented implants. Many arthroplasty registries prepare annual reports that include revision risk data for implants and they are posted on the registry websites. Arthroplasty surgeons should stay current with these registry reports on implant performance and potential outliers and keep them in mind when making implant decisions.

Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments.We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests.Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P.0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P.0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use.Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

Background The association between surgeon prescribing practices and new persistent postoperative opioid use is not well understood. We examined the association between surgeon prescribing and new persistent use among total hip arthroplasty (THA) patients. Methods A retrospective analysis of Medicare claims in Michigan was performed. The study cohort consisted of orthopedic surgeons performing THAs from 2013 to 2016 and their opioid-naive patients, aged >65 years. High-risk prescribing included high daily doses, overlapping benzodiazepine prescriptions, concurrent opioid prescriptions, prescriptions from multiple providers, or long-acting opioid prescriptions. The occurrence of a preoperative prescription, initial prescription size, and 30-day prescription dosage were examined as individual exposures. Surgeons were categorized into quartiles by prescribing practices, and multilevel hierarchical logistic regression was used to examine associations with postoperative new persistent opioid use. Results Surgeons exhibited high-risk prescribing for 66% of encounters. Patients of surgeons with the highest rates of high-risk prescribing were more likely to develop persistent use compared with patients of surgeons with the lowest rates (adjusted rates: 9.7% vs 4.6%, P = .011). Patients of surgeons with initial prescription sizes in the “high” (third) quartile (adjusted odds ratio, 2.91; 95% confidence interval, 1.53-5.51), and of surgeons in the “highest” (fourth) quartile of 30-day prescription dosage (adjusted odds ratio, 1.93; 95% confidence interval, 1.03-3.61), were more likely to develop persistent opioid use compared with patients of surgeons with low initial and 30-day prescription sizes, respectively. Conclusion The development of persistent opioid use after surgery is multifactorial, and surgeon prescribing patterns play an important role. Reducing prescribing and encouraging opioid alternatives could minimize postoperative persistent opioid use.

In this paper, we investigate the ways in which climate change-related interventions such as climate-smart agriculture (CSA) may open up—or close down—spaces for transformation. We explore the interface between worldviews, power relations and policy interventions, focusing in particular on the way that asymmetric gender and expert-farmer relations may be reinforced or contested through climate-smart agricultural interventions. It has been argued that fundamental changes required in the face of climate change can only take place through transformation across the personal, practical and political spheres. In particular, it is in the interaction between these spheres where spaces for transformation lie; for example, in the contesting of subjectivities casting farmers as passive recipients of expert advice, in the assumptions regarding what constitutes “good development”, and in how worldviews frame the way we see human-nature relations. Nevertheless, interventions like CSA are often focused mainly on changes to practices or technologies, rather than on how power relations or worldviews shape practices, food security and inequity. Through a case study of Hoima, Uganda, we examine the ways in which the implementation of climate-smart agriculture reinforces existing subjectivities and authority relations or opens up for new (and potentially more emancipatory) subjectivities. First, we describe food security and social inequality drawing on survey data from Hoima. Next, we examine how social actors such as farmers, project workers, local leaders, and government officials position particular farmers or practices as good/progressive or problematic/traditional. We then analyze how these subjectivities reflect authority relations, and the ways in which CSA reinforces or creates space for contesting these. We argue that a focus on commercial agriculture as “good” by many social actors also persists within CSA activities, and is intertwined with asymmetric gender and expert-farmer relations. Commercialization takes place within the need to increase agricultural production to feed growing urban populations. However, commercialization for the case of Uganda has also entailed state attempts to govern farmers through farmer associations, the institutional set-up through which CSA often works. A closer attention to these dynamics could potentially help create deeper transformational change through climate-smart agriculture and related climate change interventions.

Background Models of health care coverage with varying degrees of patient cost-sharing have been shown to influence health care behaviors for chronic conditions including medication adherence. The effect of insurance cost-sharing subsidies on the probability of postoperative opioid refill, however, is unclear. Methods This retrospective cohort study examined 100% Medicare claims data among patients (N = 21,781) ages 65 and older undergoing orthopedic procedures in Michigan between January 2013 and September 2016. Patients were classified based on the presence of low-income subsidy and on prior opioid exposure using Medicare Part D prescription files of drug events. We investigated the association of these factors with the probability of both initial and second postoperative opioid fill within 90 days from the date of discharge. Results In this cohort, 84.6% of patients filled an initial opioid prescription, and 66.4% refilled an opioid prescription. Patients with a full low-income subsidy had greater odds of refill within the postoperative 90 days compared with those patients without a low-income subsidy (odds ratio 1.38, 95% confidence interval 1.18–1.60). Among opioid naive patients with a full low-income subsidy, the adjusted refill rate was 61.3% (95% confidence interval 58.0–64.7%) compared with 57.6% (95% confidence interval 51.4–63.7%) among those with partial low-income subsidy and 54.2% (95% confidence interval 52.8–55.6%) among patients without low-income subsidy. Conclusion Among Medicare patients undergoing orthopedic procedures, a full medication subsidy is associated with an increased probability of opioid refill when compared with no subsidy. Going forward, it is critical to lessen financial barriers to ensure all patients have equitable access to postoperative analgesia, including both opioid and nonopioid analgesics by decreasing the patient burden of cost-sharing.

In the Internet of Things (loT) era, technology offers the ability to collect and understand information collected from the nature and environment around us. As an essential component of reliable sensing, sensors play a vital role in any IoT system. The point of departure for our work is the anticipated potential of an efficient, low-cost prototyping and testing platform for analog sensors. In this paper, we explore the fundamental building blocks of such a system: an accurate, configurable analog front end, a light-weight communication component, and efficient data-centric middleware, and a user-friendly web portal.

Internet of Things (IoT) devices have been limited in application by constraints posed by batteries. Batteries add size, weight, and upkeep costs, and limit the lifetime of devices preferred to be small, lightweight, and long-lasting. We present Apis, a software and hardware toolkit for federated power management in energy harvesting applications. By replacing batteries with rapid charging storage capacitors, circuitry to control federated energy storage, and software support to make this architecture accessible to developers, embedded devices can potentially run indefinitely with limited maintenance. We present the Apis hardware for controlling federated energy storage, supporting software, and experiments performed to validate the Apis model.

In an effort to reduce episode payment variation for joint replacement at US hospitals, the Centers for Medicare and Medicaid Services (CMS) recently implemented the Comprehensive Care for Joint Re...

The increasing readmission risk of primary total knee arthroplasty (TKA) represents a significant economic burden and public health challenge. Many have investigated the predictors of readmissions after TKA while little work has studied the associated readmission costs. This article investigated the factors affecting readmission cost after primary TKA at the time of initial discharges using clinical and resource-use information and compared the factors between 2 payer groups (Medicare-or-Medicaid and non-Medicare-nor-Medicaid groups).We used data from the Michigan State Inpatient Database of the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. We identified readmissions after primary TKA in 2012 using International Classification of Diseases, Ninth Revision, code 81.54. Total readmission cost was modeled using multivariate regression to identify predictors.Of 1358 readmissions after primary TKA, 949 were in the Medicare-or-Medicaid group, and 409 were in the non-Medicare-nor-Medicaid group. The overall mean and median total readmission costs were $9335 (standard deviation $10,528) and $6810, respectively. Significant predictors of total readmission cost for the Medicare-or-Medicaid group included length of stay (P.001), discharge disposition (P.001), number of chronic conditions (P = .001), and total cost of initial admission (P.001). Only total cost of initial admission was significant in predicting total readmission cost for the non-Medicare-nor-Medicaid group (P.001).Total cost of initial admission was a significant predictor of total readmission cost in both Medicare-or-Medicaid and non-Medicare-nor-Medicaid groups, independent of length of stay and number of chronic conditions.

Several research studies have shown the benefits of code tracing to promote student understanding of program behavior. While code tracing on specific input values is a useful starting point, students ultimately need to be able to reason rigorously and logically about the correctness of their code on all (i.e., arbitrary) inputs. Otherwise, they may make false generalizations and may achieve only a shallow understanding. Results of a multi-semester experiment to answer the following research questions: (1) With or without steps, can students learn the basics of tracing code on symbolic input values using an online tool? And how important is classroom instruction? (2) What is the impact of motivation on student attitudes in learning to reason with such a tool? Data was obtained from 297 subjects who used the online reasoning tool in a second-year software development course for CS majors. Analysis indicates that students can do symbolic reasoning to trace code and that instruction and motivation have significant impact.

Although there are frequent and recurring calls for the use of evidence to support conservation, recreation, and planning in a range of sectors, the transition to actually doing so can be challenging. In Canada, both national and provincial parks systems have faced budgetary and practical challenges to management, yet establishing linkages to support the strategic application of research and evidence has remained a long-standing priority. In Alberta, this priority is set by the provincial Plan for Parks, and a Science Strategy. However, while these documents do provide direction, they do not include a mechanism for identifying the practical and research priorities, themes, and questions to better link parks management with the scientific community, nor do they necessarily outline a way to establish complementarity between regional, provincial, and research communities. As a practical means of addressing this gap, between 2012 and 2014, Alberta Parks initiated a collaborative project with the University of Alberta (based in Edmonton, Alberta) in order to create both regional and provincial lists of priority research and policy questions. Drawing from the methods used elsewhere by Sutherland and others in Europe, the USA, and Canada, this project asked: What research and/or policy questions, if answered, could advance the knowledge base for policies, management, and research strategies that would support the relevance, accessibility, and decision-making of Alberta Parks. Based upon a series of well-attended workshops held at both the provincial and regional scale with parks’ management, researchers, and local stakeholders, this article presents the “Top 20 Questions” process, and results, within a broadly comparative framework across regions, and between province and regions. While the results point to priorities of parks’ conservation, experience management, and mandate fulfillment more generally, there are also differences between regions. These differences are most pronounced in terms of larger issues of management and climate change, but at the same time there are also commonalities between regions in terms of better assessing user needs, public support and the implications of socioeconomic and demographic changes. A key finding of this project is the prevalence of questions grounded in the social, rather than ecological, or environmental sciences, and the subsequent need to identify and operationalize methods to better link the social sciences with parks’ management and research. Subscribe to JPRA

Data center systems must adopt end-to-end resource management, covering both cyber and physical components. Modeling data center components can help to estimate and predict key performance indicators under various assumptions. This paper describes a data center modeling approach using a cyber-physical systems lens. The approach is aimed at facilitating the modeling of quality of service and energy consumption parameters to evaluate data centers under different workload and IT resources conditions, and to then compare them to one another, or compare different scenarios under which data centers operate. Results of the model are also a way to communicate and better understand data center behavior given the data center workload, and to help evaluate areas of improvement.

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a regional quality improvement effort that is focused on hip and knee arthroplasty. From its inception in 2012, MARCQI has grown to include data from 66 hospitals and surgery centers, and contains over 209,000 fully abstracted cases in its database. Using high-quality risk-standardized outcomes data, MARCQI drives quality improvement through a collaborative and nonpunitive structure. Quality improvement initiatives have included transfusion reduction, infection prevention, venous thromboembolism reduction, and reduction of discharge to nursing homes. In addition, MARCQI focuses on postmarket surveillance of implants by computing revision-risk estimates based on the cases that were registered prior to the end of 2016. This paper describes the impact of MARCQI on the quality of hip and knee arthroplasty care in the state of Michigan since its inception in 2012, and it briefly summarizes the recently released 5-year report.

Underlying link-layer protocols of well-established wireless networks that use the conventional "store-and-forward" design paradigm cannot provide highly sustainable reliability and stability in wireless communication, which introduce significant barriers and setbacks in scalability and deployments of wireless networks. In this paper, we propose a Code Embedded Distributed Adaptive and Reliable (CEDAR) link-layer framework that targets low latency and balancing en/decoding load among nodes. CEDAR is the first comprehensive theoretical framework for analyzing and designing distributed and adaptive error recovery for wireless networks. It employs a theoretically sound framework for embedding channel codes in each packet and performs the error correcting process in selected intermediate nodes in a packet's route. To identify the intermediate nodes for the decoding, we mathematically calculate the average packet delay and formalize the problem as a nonlinear integer programming problem. By minimizing the delays, we derive three propositions that: 1) can identify the intermediate nodes that minimize the propagation and transmission delay of a packet; and 2) and 3) can identify the intermediate nodes that simultaneously minimize the queuing delay and maximize the fairness of en/decoding load of all the nodes. Guided by the propositions, we then propose a scalable and distributed scheme in CEDAR to choose the intermediate en/decoding nodes in a route to achieve its objective. The results from real-world testbed "NESTbed" and simulation with MATLAB prove that CEDAR is superior to schemes using hop-by-hop decoding and destination decoding not only in packet delay and throughput but also in energy-consumption and load distribution balance.

We present the Smart Surface Network (SSN), a hardware and software platform designed for dense sensing. Sensor nodes connected to the SSN communicate using a serial bus integrated within a mountable physical surface. The hardware architecture and bus access and communication mechanisms are implemented in a self-stabilizing manner, providing robust handling of unannounced arrivals and departures of network devices. An associated API supports a peer-to-peer communication paradigm, providing access to the physical, data link, and application layers of the bus. In this paper, we describe the SSN hardware architecture and present the bus access and peer discovery algorithms. We also discuss the design of the API and describe experimental results characterizing the fairness of the bus algorithm, the efficiency of the peer discovery algorithm, and the performance of the SSN system under varying load conditions.

Objective While psychosocial factors have been associated with poorer outcomes after knee and hip arthroplasty, we hypothesized that augmented pain perception, as occurs in conditions such as fibromyalgia, may account for decreased responsiveness to primary knee and hip arthroplasty. Methods A prospective, observational cohort study was conducted. Preoperative phenotyping was conducted using validated questionnaires to assess pain, function, depression, anxiety, and catastrophizing. Participants also completed the 2011 fibromyalgia survey questionnaire, which addresses the widespread body pain and comorbid symptoms associated with characteristics of fibromyalgia. Results Of the 665 participants, 464 were retained 6 months after surgery. Since individuals who met criteria for being classified as having fibromyalgia were expected to respond less favorably, all primary analyses excluded these individuals (6% of the cohort). In the multivariate linear regression model predicting change in knee/hip pain (primary outcome), a higher fibromyalgia survey score was independently predictive of less improvement in pain (estimate −0.25, SE 0.044; P

Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions/min. A recent clinical study reported optimal return of spontaneous circulation with rates between 100 and 120/min during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. However, the relationship between compression rate and survival is still undetermined.Prospective, observational study.Data is from the Resuscitation Outcomes Consortium Prehospital Resuscitation IMpedance threshold device and Early versus Delayed analysis clinical trial.Adults with out-of-hospital cardiac arrest treated by emergency medical service providers.None.Data were abstracted from monitor-defibrillator recordings for the first five minutes of emergency medical service cardiopulmonary resuscitation. Multiple logistic regression assessed odds ratio for survival by compression rate categories (80, 80-99, 100-119, 120-139, ≥140), both unadjusted and adjusted for sex, age, witnessed status, attempted bystander cardiopulmonary resuscitation, location of arrest, chest compression fraction and depth, first rhythm, and study site. Compression rate data were available for 10,371 patients; 6,399 also had chest compression fraction and depth data. Age (mean±SD) was 67±16 years. Chest compression rate was 111±19 per minute, compression fraction was 0.70±0.17, and compression depth was 42±12 mm. Circulation was restored in 34%; 9% survived to hospital discharge. After adjustment for covariates without chest compression depth and fraction (n=10,371), a global test found no significant relationship between compression rate and survival (p=0.19). However, after adjustment for covariates including chest compression depth and fraction (n=6,399), the global test found a significant relationship between compression rate and survival (p=0.02), with the reference group (100-119 compressions/min) having the greatest likelihood for survival.After adjustment for chest compression fraction and depth, compression rates between 100 and 120 per minute were associated with greatest survival to hospital discharge.

Background— The impact of patient age on the risks of death or rehospitalization after primary prevention implantable cardioverter-defibrillator (ICD) placement is uncertain. Methods and Results— Data from 5 major ICD trials were merged: the Multicenter Automatic Defibrillator Implantation Trial I (MADIT-I), the Multicenter UnSustained Tachycardia Trial (MUSTT), the Multicenter Automatic Defibrillator Implantation Trial II (MADIT-II), the Defibrillators in Nonischemic Cardiomyopathy Treatment Evaluation Trial (DEFINITE), and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Median age at enrollment was 62 (interquartile range 53–70) years. Compared with their younger counterparts, older patients had a greater burden of comorbid illness. In unadjusted exploratory analyses, ICD recipients were less likely to die than nonrecipients in all age groups: among patients aged Conclusions— In this analysis, the survival benefit of the ICD exists but is attenuated with increasing age. The latter finding may be because of the higher burden of comorbid illness, competing causes of death, or limited sample size of older patients. There was no evidence that age modifies the association between ICD treatment and rehospitalization.

ObjectiveSocio-economic status (SES) has been positively associated with physical activity (PA) levels in adolescents. In order to tackle these social inequalities, information is needed about the underlying mechanisms of this association. The present study aimed to investigate the potential mediating role of psychosocial correlates of PA on the relationship between SES and PA in European adolescents.DesignCross-sectional study testing the mediating role of psychosocial correlates in the SES–PA association using the product-of-coefficients test of MacKinnon.SettingTen European cities in nine different countries, the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study.SubjectsAdolescents (n 2780) aged 12·5–17·49 years self-reported on PA (moderate-to-vigorous intensity PA and total PA), SES indicators (education of the mother and Family Affluence Scale) and psychosocial correlates of PA (stage of change, attitudes, awareness, modelling, social support, self-efficacy, benefits, barriers and environmental correlates).ResultsSES (Family Affluence Scale) was significantly associated with moderate-to-vigorous intensity PA. According to single-mediator models, this association was significantly mediated by stage of change (t = 3·6, P ≤ 0·001), awareness (t = 2·7, 0·001 < P ≤ 0·01), modelling (t = 4·8, P ≤ 0·001), self-efficacy (t = 2·5, 0·01